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A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation?
- A. Avoid handwashing after eating.
- B. Avoid foods prepared with tap water.
- C. Avoid eating meat.
- D. Avoid covering sores with bandages.
Correct Answer: B
Rationale: The correct answer is B: Avoid foods prepared with tap water. This is important because tap water in certain regions may be contaminated with hepatitis-causing viruses. Avoiding tap water in food preparation reduces the risk of contracting viral hepatitis. Handwashing after eating (A) is actually recommended for preventing the spread of infections. Avoiding eating meat (C) is not necessary for preventing viral hepatitis transmission. Covering sores with bandages (D) is unrelated to the prevention of viral hepatitis.
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A client seeks medical attention for intermittent signs and symptoms that suggest a diagnosis of Raynaud’s disease. The nurse should assess the trigger of these signs/symptoms by asking which?
- A. Does drinking coffee or ingesting chocolate seem related to the episodes?
- B. Does being exposed to heat seem to cause the episodes?
- C. Do the signs and symptoms occur while you are asleep?
- D. Have you experienced any injuries that have limited your activity levels lately?
Correct Answer: A
Rationale: The correct answer is A: Does drinking coffee or ingesting chocolate seem related to the episodes? This question is relevant because caffeine and chocolate are known triggers for Raynaud's disease due to their vasoconstrictive properties. By asking about these specific triggers, the nurse can gather important information to help identify potential causes of the client's symptoms.
Choice B is incorrect because exposure to heat typically alleviates symptoms of Raynaud's disease rather than causing them. Choice C is irrelevant as Raynaud's symptoms typically occur when the individual is exposed to cold or experiencing stress, not while asleep. Choice D is also incorrect as injuries limiting activity levels are not directly related to Raynaud's disease triggers.
A nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. Which of the following laboratory results should the nurse expect?
- A. Hypervolemia.
- B. Hyperkalemia.
- C. Low hemoglobin.
- D. Metabolic alkalosis.
Correct Answer: B
Rationale: The correct answer is B: Hyperkalemia. In extensive burn injuries, there is a significant release of potassium from damaged cells, leading to elevated serum potassium levels. This can result in cardiac arrhythmias and other complications. Hypervolemia (A) is less likely due to fluid shifts, low hemoglobin (C) is not typically seen in the acute phase of burn injuries, and metabolic alkalosis (D) is not a common laboratory finding in this scenario.
A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hours following a burn injury?
- A. Dextrose 5% in water.
- B. 0.45% sodium chloride.
- C. Dextrose 5% in 0.9% sodium chloride.
- D. Lactated Ringers.
Correct Answer: D
Rationale: The correct answer is D: Lactated Ringers. In the first 24 hours following a burn injury, it is crucial to administer isotonic solutions like Lactated Ringers to replace lost fluids and electrolytes effectively. Lactated Ringers contain electrolytes like sodium, potassium, and chloride, which help maintain proper fluid balance and prevent dehydration. Dextrose 5% in water (Choice A) is a hypotonic solution and may lead to fluid shifts, worsening the condition. 0.45% sodium chloride (Choice B) is hypotonic and may not provide enough electrolytes for proper fluid replacement. Dextrose 5% in 0.9% sodium chloride (Choice C) may not provide adequate electrolytes compared to Lactated Ringers.
Upon assessment, Cullen’s sign is noted. What complication of acute pancreatitis would the nurse suspect that the client might have?
- A. Pancreatic pseudocyst.
- B. Electrolyte imbalance.
- C. Internal bleeding.
- D. Pleural effusion.
Correct Answer: C
Rationale: Rationale: Cullen's sign is bluish discoloration around the umbilicus, indicating internal bleeding in acute pancreatitis. This occurs due to retroperitoneal hemorrhage tracking to the periumbilical area. Choices A, B, and D are not associated with Cullen's sign. Pancreatic pseudocyst may present with epigastric pain, electrolyte imbalance with nausea and vomiting, and pleural effusion with dyspnea.
A nurse is assessing a client. Which of the following actions should the nurse take to assess the posterior tibial pulse? (Select all that apply.)
- A. Palpate the area behind the ankle bone.
- B. Use the pads of the fingers to feel for the pulse.
- C. Compare the pulse strength with the other leg.
- D. Assess for any swelling or tenderness.
Correct Answer: A,B,C
Rationale: The correct actions to assess the posterior tibial pulse are A, B, and C. A: Palpating the area behind the ankle bone locates the posterior tibial pulse accurately. B: Using the pads of the fingers helps to detect the pulse's strength and regularity. C: Comparing pulse strength with the other leg enables the nurse to identify any discrepancies. D: Assessing for swelling or tenderness is not directly related to locating the pulse. Therefore, choices D, E, F, and G are incorrect for assessing the posterior tibial pulse.